Physician Update - Tumor on Bivouac
Tumor on Bivouac
Date: June 15, 2012
Last summer, the crack that Joshua Jordan heard coming from his back as he sneezed was odd but not worrisome. “I was sure I’d pulled a muscle,” says Jordan, 21, then in basic training at an Army base out West. He pretty much ignored the pain, knowing that “going medical” would drop him into a new platoon.
A few days later, he accidentally jabbed his left side on a sharp corner. That evening, a softball-size lump arose. But it wasn’t until after the mile run in full gear, when the softball became a football and he vomited all night, that Jordan went to the base hospital. “Other than the vomiting, I’d felt pretty good all along,” he says.
Tentative diagnosis: a detached renal artery and huge hematoma.
Other clinicians had misgivings, however, and Jordan soon found himself at The Johns Hopkins Hospital, where the diagnosis went well beyond a renal one. Before he arrived, a multidisciplinary team had begun to gather—three surgeons noted for bold approaches as much as expertise, and their colleagues in oncology, pathology and radiology.
Ultrasound revealed a left testicular tumor. “That it was a teratoma wasn’t surprising,” says urologist Mohamad Allaf, the case’s team leader. The cancers are rare “unless you’re between 20 and 39—when young men often ignore symptoms,” he says. “Usually, we’ll see a patient whose tumor is localized and remove the testicle. If it’s spread to the retroperitoneum—metastases are typically less than 4 centimeters—you offer chemotherapy; the tumor shrinks; you remove what’s left and follow with lymph node dissection.”
That wasn’t Jordan’s case, however: Images showed a retroperitoneal mass 21 cm across. It looked to have invaded his inferior vena cava, left kidney and aorta. Scans also revealed a compression fracture—remember the sneeze?—of the L3 vertebra. And a lesion in that and another lumbar vertebral body would greatly complicate treatment.
The young man’s care began with a left orchiectomy followed by standard systemic chemotherapy that reduced the abdominal mass by half. Of the two vertebrae, only the L3 had remaining pathology. “Still,” says Allaf, “the tumor was massive, and because of the extent of surgery and potential complications, removing it wouldn’t be trivial.”
Day 1 began with him face down, the prone approach necessary to later lift away tumor en bloc. That first day, Wolinsky removed the L3’s posterior elements and secured enough metal above and below to anchor the titanium “cage” that would prevent spinal collapse. Diamond-edged wire saws were left in overnight, positioned for the next day’s surgery. Although spondylectomies are uncommon worldwide, Wolinsky and a colleague have performed some 50 of the walking-on-eggshells vertebra removals, a U.S. record.
Next morning, with Jordan now on his back, Allaf gently scraped off the roughly two-pound teratoma (verified) that draped like so much wet tissue over the aorta, and excised the infiltrated left kidney and adrenal gland. Because the tumor had entered the vena cava, removing it left a considerable hole over which Black tacked graft tissue. Finally, with the tumor bulk gone, Wolinsky sawed away the diseased vertebral body, working gently around the spinal cord. “The vertebra-plus-tumor and adjacent discs came out in a piece,” he says.
Now the stunner: “In these very complex situations, you do what you can to make the best of things,” says Allaf. “But in Josh’s case, though his very specialized rehab at Hopkins will be long, all systems, otherwise, are fully functioning.” I rode my bike last week, Jordan says. I just couldn’t jump the curbs.
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